National burns and scalds conference

Medical professionals count bath water scalds as among the worst injuries that a child can suffer.They cause severe facial and bodily scarring which can require years of painful skin grafts. A scald over more than 20% of the body – not uncommon if a small child falls into a bath of hot water – has the same impact as being hit by a bus.

The scale of the problem

Each year in the UK around 2,000 children attend A&E following bath water scalds. 1 In England during 2010/11, around 400 children aged 0–14 were admitted to hospital with bath water scalds – 57% of all people admitted with these injuries.2 Children from the most deprived one-fifth of wards are three times as likely to be admitted to hospital with burns and scalds as those from the most affluent fifth.3

Key costs for treating bath water scalds in 0-14 year olds

Cost4

Acute treatment costs

Cost of a bed day in a specialist burns facility, to treat a minor bath water scald

£750

Cost of a bed day in a burns centre intensive care unit

£2,500

Cost of treating one very serious scald

£72,246­–£172,821

Cost of treating one serious scald

£41,134

Total annual cost of acute treatment

£39.2 million

Lifetime medical costs

Average lifetime medical costs per child

£16,116

Total lifetime medical costs generated in one year

£6.6 million

Economic costs

Lost output per child

£18,920

Human cost per child

£130,110

The financial costs

Acute treatment

The British Burn Association (BBA) calculates that serious ‘Category A’ bath water scalds require treatment in a specialist burns unit, at a cost of £750 a day. Very serious ‘Category B’ scalds are likely to require treatment in a burns centre intensive care unit (ICU), at a cost of £2,500 a day. 4

In addition to the BBA figures used in this article, the Department of Communities and Local Government suggests that costs may be even higher. They calculate the cost of a ‘normal’ bed day for a burns victim at £1,345, equivalent to the cost of General Level 2 intensive care nursing. They give the cost of a hospital bed day in an ICU with Level 3 care as £3,303.

The BBA estimate that three quarters of Category B cases require intensive care nursing, with an average stay of 40 days. Victims of the most severe bath water scalds might stay in ICU for as long as 100 days.

The package of care for a severe bath water scald involves:

ambulance and A&E attendance

surgical procedures including grafts and plastic surgery

pain management

community nursing and health visiting

physiotherapy and play specialists.

In 2008 the BBA calculated that it costs £72,246­ to treat a Category B scald without intensive care and £172,821 if intensive care is needed. Treating a Category A scald costs £41,134. The total annual acute treatment cost for 0–14 year olds with severe bath water scalds is £39.2 million.4

Long-term treatment

Children who have suffered a serious bath water scald need follow-up medical treatment until they stop growing. Long-term treatment for a severe scald involves:

surgical procedures – an average of 3 over 15-16 years

dressings and post-discharge clinic visits - around 8 appointments in the first 3 months

scar review consultations - every 2-3 months for 18-24 months

annual outpatient appointments for 13 years

pressure garments for the first 2 years.

The BBA has calculated the average cost for this package of care as £16,116 but says this can rise to as much as £50,000 for the most severe cases. 4 Based on the average cost of long-term treatment, the 400 children admitted to hospital with bath water scalds generated lifetime medical costs of around £6.6 million.

Cost to the economy

In addition to the medical costs, every serious bath water scald generates an economic cost of £162,725. 4 This includes £130,110 in human costs, to account for the pain, grief and suffering experienced by the patient and their family. It also includes £18,920 in lost output, caused by parents taking time off work to care for their child. The CBI absence and workplace survey 2011 gives the costs to the economy for each day lost from work as £760 per employee per working day.

For the 400 cases among 0-14 year olds in England in 2010/11, this gives a cost to the economy of around £65 million. The true cost could be much higher for this age group, as young victims are likely to live longer and suffer a much greater loss of output over the course of their lives.

The cost burden for families

Coping with a child who has a severe bath water scald can place a substantial strain on family finances. Parents have to pay the costs of travelling to the regional burns unit where their child is being treated, which may be hundreds of miles from the family home.

Parents may have to take large amounts of time off work to stay with their child during the acute treatment phase, as well as for frequent clinic visits and outpatient appointments. Time off work is often taken as unpaid leave, leading to a significant loss of earnings.

The emotional costs

The effect on the child

Serious bath water scalds can cause significant social and psychological problems. While scars may be highly visible, ‘hidden’ problems can include chronic pain and itching, disturbed sleep, social anxiety and psychosexual issues. Along with repeated stays in hospital and frequent outpatient appointments, these problems can have an adverse affect on a child’s education, future employment prospects and lifetime earnings.

Psychosocially, children are affected whenever they are expected to expose their scars, for example during swimming or school sports. Since bath scalds invariably affect the groin area, children can develop psychosexual problems during their teenage years. A scald-scarred teenager can feel extremely anxious about revealing previously concealed scarring to someone they are attracted to.

The effect on families

Bath water scalds can trigger a lifetime of guilt for families. If one parent was absent at the time of the accident, they may blame the parent who was present. Trying to cope with such severe injuries places enormous pressure on parents, with burns professionals reporting very high rates of relationship breakdown.

Parents are likely to spend significant periods of time away from home while their child is being treated at a regional burns unit, which may be hundreds of miles away. They then have to commit time to outpatient appointments and managing their child’s injuries at home. All of this can be highly disruptive to family life and have a particular effect on siblings.

The child’s perspective: Darren’s story

By the age of 17, Darren Ferguson had undergone 59 major operations, numerous minor operations and laser surgery to treat the bath water scald he suffered as a young child. He says: “I can’t disguise the fact that I have been injured or recently undergone surgery. This is a fact of life for me. The constant staring – by kids and by grown-ups who should know better – makes life difficult for me.”

The pain and anxiety associated with repeated surgical procedures has had a knock-on effect on Darren’s education. “When I was a youngster, and I was due to undergo an operation, I found it difficult to concentrate on school work before the op. When I am in pre-op, I am always anxious because I know that – however skilful my surgeons are – I will always be in pain when I wake up. That is guaranteed. And when I go to sleep each night, I know that I will be in pain when I awake.”

Surgeons call bath water scalds ‘life-changing injuries’ and Darren’s experience confirms this view. “My physical injuries are plain for all to see but I have others that cannot be seen. I was robbed of my childhood because I had to grow up and face things that none of my friends had to face.”

The parent’s perspective: Claire’s story 5

Claire’s son Jack experienced a serious bath water scald at the age of 2. He was rushed to hospital and airlifted to a specialist burns unit where he was found to have burns over 76% of his body. He spent 4.5 months in the high dependency unit, undergoing 15 life-saving operations and numerous skin grafts.

After leaving hospital, Jack wore pressure garments for 18 months and Claire had to remove them twice a day to apply cream. This was very painful and Claire says that, “the only thing that kept me going was knowing that this painful process would help to reduce the scarring”. Jack’s feet were badly burned, so he wore special boots and attended physiotherapy sessions to help him learn to walk again.

Now 8 years old, Jack still needs daily special care. “I have to apply cream every day to stop his skin drying out and make sure he drinks plenty of liquids, because his sweat glands have been damaged. And there are many hospital operations yet to come – he will need skin grafts until he stops growing. As he gets older, he will have to come to terms with his psychological scars as well as his physical ones.”

How could it be prevented?

Bath water scalds in young children typically occur in the few seconds that a parent is distracted, for example by a sibling crying in another room or the need to fetch a towel. Because a young child’s skin is thin, it can take just 5 seconds for a toddler to suffer a third degree burn from water at 60C. Hot water must be stored at high temperatures to avoid the risk of legionella, but fitting a thermostatic mixing valve (TMV) can prevent the risk of scalds.

TMVs regulate the maximum hot water temperature to 48C – cool enough so that a child can’t be scalded within seconds, but hot enough for an adult to enjoy a hot bath. They cost from around £20 and can be very simply fitted by a plumber.